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Set
ting
the
Rec
ord
Str
aigh
t….T
he M
yths
of
Des
flur
ane
Dec
iphe
red
Mar
ibet
h M
assi
e, C
RN
A, M
SA
ssis
tant
Pro
fess
or in
Clin
ical
Nur
sing
Ass
ista
nt P
rogr
am D
irec
tor,
Col
umbi
a U
nive
rsit
y S
choo
l of
Nur
sing
Pro
gram
in
Nur
se A
nest
hesi
a, N
ew Y
ork
NY
Sta
ff N
urse
Ane
sthe
tist
, The
Joh
ns H
opki
ns
Hos
pita
l, B
alti
mor
e, M
D
Do
you
know
if t
hese
are
m
yths
or
trut
hs?
•Y
ou c
anno
t us
e D
esfl
uran
e w
ith
LMA
’s,
espe
cial
ly in
ped
iatr
ics,
due
to
the
incr
ease
d in
cide
nce
of a
irw
ay ir
rita
bilit
y•
If y
ou w
ant
the
fast
est
wak
eup
poss
ible
, us
e P
ropo
fol o
ver
the
inha
led
anes
thet
ics
•D
esfl
uran
e ca
uses
too
muc
h ta
chyc
ardi
a an
d hy
pert
ensi
on•
If y
ou w
ant
to b
e ec
onom
ical
and
sti
ll ha
ve
a fa
st w
akeu
p, u
se I
sofl
uran
e th
roug
hout
th
e ca
se t
hen
swit
ch t
o D
esfl
uran
e at
the
en
d
Now
som
e th
ings
are
tr
ue…
Som
e ba
ckgr
ound
info
on
inha
led
anes
thet
ics
Insp
ired
and
Alv
eola
r A
nest
hetic
In
spire
d an
d A
lveo
lar
Ane
sthe
tic
Con
cent
ratio
nsC
once
ntra
tions
NN22OO
Des
flura
neD
esflu
rane
Isof
lura
neIs
oflu
rane
Hal
otha
neH
alot
hane
11
0.8
0.8
0.6
0.6
0.4
0.4
0.2
0.2 00
001010
20203030
Min
utes
of A
dmin
istr
atio
nM
inut
es o
f Adm
inis
trat
ion
FFAA/F/F
II
Sev
oflu
rane
Sev
oflu
rane
Yas
uda
et a
l.Y
asud
a et
al.
Ane
sth
Ana
lg. 1
991.
Ane
sth
Ana
lg. 1
991.
Sol
ubili
ty in
Blo
od
1960
1960
00112233
Hal
otha
ne, 2
.54
Hal
otha
ne, 2
.54
Isof
oran
e, 1
.46
Isof
oran
e, 1
.46
Des
flura
ne, 0
.42
Des
flura
ne, 0
.42
Blo
od:G
as
Blo
od:G
as
Par
titio
n P
artit
ion
Coe
ffici
ent
Coe
ffici
ent
Yea
r of I
ntro
duct
ion
Into
Pra
ctic
eY
ear o
f Int
rodu
ctio
n In
to P
ract
ice20
0020
0019
8019
80
Sev
oflu
rane
, 0.6
9S
evof
lura
ne, 0
.69
Impl
icat
ions
of
Low
S
olub
ility
•M
ore
rapi
d w
ash-
in
•G
reat
er a
nest
heti
c co
ntro
l and
pr
ecis
ion
•M
ore
rapi
d em
erge
nce
from
an
esth
esia
•P
oten
tial
ly g
reat
er e
cono
my
thro
ugh
mor
e ra
pid
reco
very
•M
ay e
limin
ate
N2O
wit
hout
ki
neti
c di
sadv
anta
ge
MA
C (
Pot
ency
)
•C
once
ntra
tion
of
drug
tha
t pr
even
ts
skel
etal
mus
cle
mov
emen
t in
re
spon
se t
o a
surg
ical
inci
sion
in
50%
of p
atie
nts
•R
efle
cts
the
part
ial p
ress
ure
at t
he
site
of
acti
on (
brai
n)•
Mos
t us
eful
inde
x of
ane
sthe
tic
pote
ncy
•S
imila
r M
AC
con
cent
rati
ons
prod
uce
equa
l dep
ress
ion
of C
NS
MA
C•
MA
C:
•M
AC
tha
t pr
even
ts s
kele
tal m
uscl
e m
ovem
ent
in 5
0% o
f pa
tien
ts•
MA
C-A
wak
e:
•M
AC
at
whi
ch 5
0% o
f pt
s w
ill r
espo
nd t
o th
e co
mm
and
“Ope
n yo
ur e
yes”
•U
sual
ly a
ssoc
iate
d w
ith
a lo
ss o
f re
call
(~1/
3 M
AC
) •
MA
C-B
AR
:•
MA
C n
eces
sary
to
bloc
k ad
rene
rgic
re
spon
se t
o sk
in in
cisi
on (↑H
R,↑
B/P
)•
Exp
ress
ed a
s M
AC
-BA
R50
or M
AC
-BA
R95
•E
xcee
ds t
he r
equi
rem
ent
of M
AC
Inha
led
Age
nts:
Blo
od/G
as
Par
titi
on C
oeff
icie
nt
•D
esfl
uran
e
0
.42
% (
Fast
ons
et)
•N
itro
us O
xide
0
.47
% (
Fast
ons
et)
•S
evof
lura
ne
0
.69
% (
Med
ium
)•
Isof
oran
e
1.4
3 %
(M
ediu
m)
•E
thra
ne
1
.9 %
(M
ediu
m)
•H
alot
hane
2
.4 %
(S
low
)
Hum
an T
issu
e:B
lood
P
arti
tion
Coe
ffic
ient
s
Des
flura
neD
esflu
rane
Sev
oflu
rane
Sev
oflu
rane
Isof
oran
eIs
ofor
ane
Hal
otha
neH
alot
hane
NN22OO
Fat
Fat
27274848
45455151
2.3
2.3
Bra
inB
rain
1.3
1.3
1.7
1.7
1.6
1.6
1.9
1.9
1.1
1.1
Hea
rtH
eart
1.3
1.3
1.8
1.8
1.6
1.6
1.8
1.8
––Li
ver
Live
r1.
31.
31.
81.
81.
81.
82.
12.
10.
80.
8K
idne
yK
idne
y1.
01.
01.
21.
21.
01.
01.
21.
2––
Mus
cle
Mus
cle
2.0
2.0
3.1
3.1
2.9
2.9
3.4
3.4
1.2
1.2
Elim
inat
ion
of in
hale
d an
esth
etic
s
Long
Long
-- Ter
m E
limin
atio
nTe
rm E
limin
atio
n
1010-- 44
1010-- 55
1010-- 66
1010-- 77
0011
2233
4455
Day
s of
Elim
inat
ion
Day
s of
Elim
inat
ion
Hal
otha
neH
alot
hane
Isof
lura
neIs
oflu
rane
Sevo
flura
neSe
voflu
rane
Des
flura
neD
esflu
rane
FF AA/F/F
A0A0
Yasu
da e
t al.
Yasu
da e
t al.
Ane
sth
Anal
g. 1
991.
Anes
th A
nalg
. 199
1.
Tox
icit
y of
Inh
aled
A
gent
s•
Met
abol
ism
to
toxi
c pr
oduc
ts is
th
e m
echa
nism
of
occu
rren
ce•
Can
dam
age
liver
and
kid
ney
•M
ay le
ad t
o “h
epat
otox
icit
y”or
“n
ephr
otox
icit
y”•
Use
age
nts
that
hav
e ve
ry lo
w
met
abol
ites
to
prev
ent
kidn
ey
or li
ver
dise
ase
Inha
led
Age
nts:
%
Met
abol
ized
Age
nt
% R
ecov
ered
as
Uri
nary
Met
abol
ites
•H
alot
hane
20
.00
%•
Sev
oflu
rane
5.00
%•
Eth
rane
2.
00 %
•
Isof
lura
ne
0.
20 %
•D
esfl
uran
e
0.
02 %
•N
itro
us O
xide
0.
004
%
Com
poun
d A
•S
evof
lura
ne d
ecom
pose
s in
CO
2 ab
sorb
ents
to
Com
poun
d A
•In
rat
s, k
idne
y da
mag
e oc
curs
if
> 50
PP
M•
Hum
ans
form
Com
poun
d A
a lo
t le
ss t
han
rats
•R
enal
eff
ects
in h
uman
s is
co
ntro
vers
ial
•M
ore
rese
arch
is n
eede
d
Avo
idin
g C
ompo
und
A
Con
cern
•P
oten
tial
for
dam
age
exis
ts f
or
prol
onge
d se
vofl
uran
e an
esth
esia
, es
peci
ally
at
high
er c
once
ntra
tion
s an
d lo
wer
FG
F ra
tes
•P
acka
ge in
sert
indi
cate
s th
at it
sh
ould
not
be
used
at
a FG
F ra
te o
f <
1 L/
min
for
mor
e th
an 2
MA
C-h
ours
•
If c
ase
is >
2 h
ours
, the
FG
F ra
te
shou
ld b
e in
crea
sed
to 2
L/m
in o
r m
ore
Car
bon
Mon
oxid
e (C
O)
Tox
icit
y•
Occ
urs
whe
n al
l IA
’s d
egra
ded
by d
ry s
oda
lime
or b
aral
yme
•D
oes
not
occu
r w
ith
fully
hy
drat
ed a
bsor
bent
s•
Com
mon
sce
nari
o:
* M
onda
y m
orni
ng c
ase
and
gas
has
been
left
on
over
the
w
eeke
nd, d
ryin
g th
e ab
sorb
ent
Avo
idin
g th
e pr
oble
m
of C
O T
oxic
ity
•U
se f
resh
abs
orbe
nt•
Use
sod
a lim
e ra
ther
tha
n ba
rium
hyd
roxi
de•
Use
the
new
CO
2 ab
sorb
ent
calle
d “A
mso
rb”
•P
reve
nts
anes
thet
ic b
reak
dow
n th
at w
ould
lead
to
CO
for
mat
ion
•T
urn
off
gas
whe
n ca
se
com
plet
e
Dur
atio
n of
inha
led
anes
thet
ics
Term
inal
Dec
rem
ent
Term
inal
Dec
rem
ent
Bai
ley
JM. A
nest
h A
nalg
. 199
7;85
:681
.B
aile
y JM
. Ane
sth
Ana
lg. 1
997;
85:6
81.
Dur
atio
n of
Ane
sthe
tic
Dur
atio
n of
Ane
sthe
tic
Adm
inis
tratio
n (m
in)
Adm
inis
tratio
n (m
in)
100
100 6060 2020 0040408080
005050
100
100
150
150
200
200
250
250
300
300
350
350
90%
90%
Dec
rem
ent
Dec
rem
ent
Tim
eTi
me
(min
)(m
in)
Enf
lura
neE
nflu
rane
Isof
lura
neIs
oflu
rane
Sev
oflu
rane
Sev
oflu
rane
Des
flura
neD
esflu
rane
Mas
k In
duct
ion
Ped
iatr
ic m
ask
indu
ctio
n
Air
way
irri
tabi
lity
Zw
ass
Zw
ass
et a
l. A
nest
hesi
olog
y. 1
992;
76:3
73.
et a
l. A
nest
hesi
olog
y. 1
992;
76:3
73.
020406080100
Des
flura
neD
esflu
rane
Hal
otha
ne
Mild
Mod
erat
eS
ever
eC
ough
ing
(% o
f Pat
ient
s)
Indu
ctio
n A
gent
:P
rem
edic
atio
n:Y
esN
oN
o
Airw
ay E
vent
s D
urin
g In
duct
ion:
A
irway
Eve
nts
Dur
ing
Indu
ctio
n:
Des
flura
ne v
sD
esflu
rane
vs
Hal
otha
neH
alot
hane
7891
11
Ped
iatr
ic m
aint
enan
ce
Air
way
com
plic
atio
ns
Mai
nten
ance
of A
nest
hesi
a vi
a M
aint
enan
ce o
f Ane
sthe
sia
via
Face
mas
k:
Face
mas
k: D
esflu
rane
vs
Des
flura
ne v
sH
alot
hane
Hal
otha
ne
Dav
is e
t al.
Ane
sthe
siol
ogy.
199
4;80
:298
.D
avis
et a
l. A
nest
hesi
olog
y. 1
994;
80:2
98.
02550
Des
flura
neH
alot
hane
Airw
ay
Com
plic
atio
ns(%
of P
atie
nts)
04.
3
LMA
use
in p
edia
tric
s
Air
way
irri
tabi
lity
Sev
oflu
rane
vs.
Des
flur
ane
Con
side
rati
ons
wit
h th
e pe
diat
ric
popu
lati
on
0255075
Des
flura
neH
alot
hane
Emer
genc
e Ag
itatio
n(%
of P
atie
nts)
Rec
over
y Fr
om
Rec
over
y Fr
om D
esflu
rane
Des
flura
nein
Chi
ldre
n:
in C
hild
ren:
Em
erge
nce
Agita
tion
Emer
genc
e Ag
itatio
n
Dav
is e
t al.
Ane
sthe
siol
ogy.
199
4;80
:298
.D
avis
et a
l. A
nest
hesi
olog
y. 1
994;
80:2
98.
50
21
Em
erge
nce
agit
atio
n
Aono
Aono
et a
l. An
esth
esio
logy
. 199
7;87
:129
8.et
al.
Anes
thes
iolo
gy. 1
997;
87:1
298.
Emer
genc
e Ag
itatio
n W
ith
Emer
genc
e Ag
itatio
n W
ith S
evof
lura
neSe
voflu
rane
0204060
Hal
otha
neSe
voflu
rane
Hal
otha
neSe
voflu
rane
Emer
genc
e Ag
itatio
n(%
of P
atie
nts)
Pres
choo
l Age
Scho
ol A
ge
10
40
15.4
11.5
Em
erge
nce
agit
atio
n
Coh
en e
t al.
Coh
en e
t al.
Ane
sth
Ana
lgAn
esth
Ana
lg. 1
999;
88:S
292.
. 199
9;88
:S29
2.
Wha
t W
hat F
enta
nyl
Fent
anyl
Dos
e M
ay P
reve
nt
Dos
e M
ay P
reve
nt
Emer
genc
e Ag
itatio
n in
Chi
ldre
n?Em
erge
nce
Agita
tion
in C
hild
ren?
••In
duct
ion:
NIn
duct
ion:
N22O
, O
, sev
oflu
rane
sevo
flura
ne
••M
aint
enan
ce: N
Mai
nten
ance
: N22O
, O
, des
flura
nede
sflu
rane
4% to
6%
4% to
6%
••A
nalg
esia
: A
nalg
esia
: fen
tany
lfe
ntan
yl1.
25, 1
.875
, 2.8
, 4.2
1.25
, 1.8
75, 2
.8, 4
.2m
cgm
cg/k
g, a
djus
ted
by “u
p/k
g, a
djus
ted
by “u
p --do
wn”
tech
niqu
edo
wn”
tech
niqu
e
••A
gita
tion
asse
ssed
Agi
tatio
n as
sess
ed
••M
inim
al e
ffect
ive
dose
to p
reve
nt e
mer
genc
e M
inim
al e
ffect
ive
dose
to p
reve
nt e
mer
genc
e ag
itatio
n w
ithou
t pro
long
ing
emer
genc
e tim
e:
agita
tion
with
out p
rolo
ngin
g em
erge
nce
time:
2.
562.
56m
cgm
cg/k
g/k
g
Em
erge
nce
Effe
ct o
f Ef
fect
of F
enta
nyl
Fent
anyl
Des
flura
neD
esflu
rane
// Sev
oflu
rane
Sevo
flura
neM
aint
enan
ceM
aint
enan
ce: :
Ext
ubat
ion
Extu
batio
nan
d R
ecov
ery
Tim
ean
d R
ecov
ery
Tim
e
6.9
9.1
0510152025
Tim
e(m
in)
Des
flura
neSe
voflu
rane
Coh
en e
t al.
C
ohen
et a
l. A
nest
h An
alg
Anes
th A
nalg
2000
;90:
S35
2.20
00;9
0:S3
52.
Fast
-Tra
ck E
ligib
ility
Aft
er
Am
bula
tory
Lap
aros
copi
c S
urge
ry
* P
<.05
vs.
oth
er g
roup
s*
P<.
05 v
s. o
ther
gro
ups
N=4
0 pe
r gro
upN
=40
per g
roup
Son
g et
al.
Am
nest
y A
nalg
Son
g et
al.
Am
nest
y A
nalg
.. 199
8;86
:267
1998
;86:
267.
9.8
11.3
14.7
1011
.7
15.7
0246810121416
Min
utes
Orie
ntat
ion
Aldr
ete
Sco
re o
f 10
Des
flura
neS
evof
lura
neP
ropo
fol
****
Mov
emen
t du
ring
su
rger
y
Neu
rolo
gic
Mon
itor
Dat
a:
Pre
dict
or o
f Fa
st-T
rack
E
ligib
ility
Aft
er A
mbu
lato
ry
Ane
sthe
sia?
* P
<.05
* P
<.05
Tota
l N=6
0To
tal N
=60
Son
g et
al.
Ane
sth
Ana
lgS
ong
et a
l. A
nest
h A
nalg
.. 199
8;87
:124
5.19
98;8
7:12
45.
7
4
13
10
02468
10
12
14
Min
ute
s
Aw
aken
ing
Fas
t-T
rack
Elig
ible
Pro
pof
olD
esflu
ran
e
**
**
Em
erge
nce
and
Ext
ubat
ion:
D
esfl
uran
e vs
. Iso
fora
ne, P
ropo
fol,
and
Sev
oflu
rane
Des
flur
ane
Sev
oflu
rane
Iso
fora
neP
ropo
fol
Bea
ussi
er e
t al
1
Em
erge
nce
(min
)12
*24
Ext
ubat
ion
(min
)16
*33
Juvi
n et
al2
Em
erge
nce
(min
5.6*
11.5
11.9
Ext
ubat
ion
(min
)6.
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.19.
9
Nat
hans
on e
t al
3
Em
erge
nce
(min
)4.
8*7.
8E
xtub
atio
n (m
in)
5.1*
8.2
1. C
an J
Ana
esth
. 199
8;45
:429
.1.
Can
J A
naes
th. 1
998;
45:4
29.
2. A
nest
h A
nalg
. 199
7;85
:647
.2.
Ane
sth
Ana
lg. 1
997;
85:6
47.
3. A
nest
h A
nalg
. 199
5;81
:118
6.3.
Ane
sth
Ana
lg. 1
995;
81:1
186.
* P
* P≤≤ .
05 v
s. o
ther
gro
ups
.05
vs. o
ther
gro
ups
Fast
-Tra
ck E
ligib
ility
: D
esfl
uran
e vs
. Sev
oflu
rane
an
d P
ropo
fol
Pat
ient
s Fa
st-T
rack
Elig
ible
on
Arr
ival
in P
AC
U
26%
*
75%
90%
020406080100
Des
flura
neSe
voflu
rane
Prop
ofol
% * P
<.05
vs.
oth
er 2
gro
ups
* P
<.05
vs.
oth
er 2
gro
ups
Son
g et
al.
Ane
sth
Ana
lg. 1
998;
86:2
67.
Son
g et
al.
Ane
sth
Ana
lg. 1
998;
86:2
67.
Em
erge
nce
and
reco
very
com
pari
sons
1011
5
21
17
11
0510152025
Tim
e(m
in)
Em
erge
nce
(OR
)R
ecov
ery
(PA
CU
)
Hal
otha
neS
evof
lura
neD
esflu
rane
*
*
Em
erge
nce
in B
aria
tric
P
atie
nts
•D
ue t
o it
s lo
w t
issu
e &
fat
sol
ubili
ty,
obes
e pa
tien
ts h
ave
less
ane
sthe
tic
agen
t st
ored
in t
issu
e an
d fa
t w
ith
desf
lura
ne•
Em
erge
nce
is m
ore
rapi
d•
Rec
over
y is
mor
e co
nsis
tent
tha
n pr
opof
ol o
r Is
ofor
ane
Juve
n et
al.
A &
A, 2
000,
91:
714
-19
May
be t
his
is a
litt
le m
ore
than
bar
iatr
ic s
urge
ry
Qui
cker
Bar
iatr
ic
Em
erge
nce
•C
an m
ove
self
fro
m O
R t
able
•Le
ss b
ack
stre
ss o
n st
aff
•Le
ss r
isk
for
aspi
rati
on•
Less
win
dow
for
nau
sea
•Le
ss O
R t
ime
(exp
ensi
ve)
•C
RN
A “
look
s go
od”
•S
taff
fee
ls C
RN
A is
a g
ood
prac
titi
oner
•P
atie
nt f
eels
mor
e aw
ake
and
can
be d
isch
arge
d qu
icke
r
Ret
urn
to N
orm
al
Act
ivit
y•
Gro
up o
f pa
tien
ts u
nder
goin
g ou
tpat
ient
gyn
ecol
ogic
al s
urge
ry•
Dis
char
ge t
ime
•S
evof
lura
ne c
ompa
red
to
Des
flur
ane
•3
hrs
vs. 3
.5 h
rs
•N
umbe
r w
ho r
etur
ned
to n
orm
al
acti
vity
on
firs
t po
stop
erat
ive
day
•S
evof
lura
ne c
ompa
red
to
Des
flur
ane
•15
vs.
29
Rec
over
y of
Cog
niti
ve F
unct
ion
•A
gent
s w
ith
low
sol
ubili
ty w
ill
offe
r qu
icke
r w
ake
up &
ret
urn
of c
ogni
tive
fun
ctio
n•
Will
allo
w a
bilit
y to
ass
ess
neur
olog
ical
fun
ctio
n qu
icke
r•
Low
sol
ubili
ty a
gent
s w
ork
wel
l fo
r lo
ng c
ases
, the
eld
erly
, the
ob
ese
Con
side
rati
on w
ith
Oth
er P
atie
nts
•T
he e
lder
ly w
ith
incr
ease
d pr
opor
tion
s of
fat
•T
he n
orm
al-w
eigh
t pa
tien
t w
ho is
no
t in
sha
pe a
nd p
roba
bly
has
incr
ease
d pr
opor
tion
s of
fat
•T
he e
lder
ly p
atie
nt w
ho is
als
o ob
ese
•T
he p
edia
tric
pat
ient
who
has
a
larg
e pr
opor
tion
of
fat
•A
lso,
con
side
r th
e ob
ese
pati
ent
as a
n ol
der
pati
ent
due
to t
he
stre
ss o
n hi
s or
her
org
ans
Des
flur
ane
and
olde
r pa
tien
ts•
Low
est
solu
bilit
y of
all
agen
ts•
Hig
h le
vel o
f st
abili
ty•
Low
deg
ree
of m
etab
olis
m•
Rap
id c
ontr
ol o
f an
esth
etic
de
pth
•R
apid
con
trol
of
hem
odyn
amic
s•
Enh
ance
d qu
alit
y of
rec
over
y
Con
side
rati
ons
wit
h th
e ge
riat
ric
popu
lati
on
Effe
ct o
f Agi
ng o
n M
AC o
f Des
flura
neEf
fect
of A
ging
on
MAC
of D
esflu
rane
Age
(yr)
Age
(yr)
100%
O10
0% O
2260
% N
60%
N22OO
< 1
< 1
9.2%
9.
2% --
10%
10%
7.5%
7.5%
1 1 -- 1
2128.
1%
8.1%
--9.
1%9.
1%6.
4%6.
4%18
18
--3030
7.3%
7.3%
4%4%31
31
--6060
6%6%2.
8%2.
8%>
60>
605.
2%5.
2%1.
7%1.
7%
Supr
ane
Supr
ane®®
(des
flura
ne, U
SP) p
resc
ribin
g in
form
atio
n.(d
esflu
rane
, USP
) pre
scrib
ing
info
rmat
ion.
Hem
odyn
amic
Eff
ects
Sym
path
etic
Res
pons
e to
S
ympa
thet
ic R
espo
nse
to
Dec
reas
ed B
lood
Pre
ssur
eD
ecre
ased
Blo
od P
ress
ure
Muz
i, Eb
ert.
Anes
thes
iolo
gy. 1
995;
82:9
22.
* P<.
05*
P<.
05vsvs
cont
rol f
or s
ame
anes
thet
icco
ntro
l for
sam
e an
esth
etic
† P
<.05
bet
wee
n an
esth
etic
s†
P<.
05 b
etw
een
anes
thet
ics
Mus
cle
Sym
path
etic
N
erve
Act
ivity
(% o
f con
trol)
MA
C
120 80 40 2060100 0
0.5
1.0
1.5
Isof
lura
ne
Des
flura
ne
† ** *
* *
Hea
rt R
ate
Cah
alan
et a
l. A
nest
h A
nalg
. 199
1;73
:157
; Mal
an e
t al.
Ane
sthe
siol
ogy.
199
5;83
:918
; S
teve
ns e
t al.
Ane
sthe
siol
ogy.
197
1;35
:8; W
eisk
opf e
t al.
Ane
sth
Ana
lg.
1991
;73:
143.
95 85 75 65 600
1.0
2.0
Hea
rt R
ate
(bpm
)
MAC
Isof
lura
ne-O
2
Sev
oflu
rane
-O2
Des
flura
ne-O
2
Des
flura
ne-N
2O
90 80 70
Min
imiz
ing
the
Sym
path
etic
Res
pons
e to
R
apid
Inc
reas
es in
Des
flur
ane
Con
cent
rati
on
•Inc
reas
ed h
eart
rat
e an
d bl
ood
pres
sure
•Tra
nsie
nt r
espo
nse
•Doe
s no
t oc
cur
in a
ll pa
tien
ts, l
ess
likel
y in
eld
erly
pat
ient
s•T
reat
men
t m
ay n
ot b
e ne
eded
due
to
brie
f du
rati
on•N
arco
tic
pret
reat
men
t m
inim
izes
the
re
spon
se
Rec
omm
enda
tion
s to
min
imiz
e he
mod
ynam
ic r
espo
nse
•C
onsi
der
IV o
pioi
ds p
rior
to
incr
easi
ng d
esfl
uran
e co
ncen
trat
ion
•In
itia
l vap
oriz
er s
etti
ng: 3
% t
o 6%
de
sflu
rane
•In
crem
ents
: 1%
del
iver
ed
conc
entr
atio
n•
Con
side
r a
shor
t-ac
ting
bet
a bl
ocke
r su
ch a
s es
mol
ol
Des
flur
ane
Mai
nten
ance
Des
flura
neD
esflu
rane
Mai
nten
ance
:M
aint
enan
ce:
Ach
ievi
ng S
urgi
cal D
epth
Ach
ievi
ng S
urgi
cal D
epth
••D
eliv
ered
Del
iver
edde
sflu
rane
desf
lura
neco
ncen
tratio
n sh
ould
be
grad
ually
incr
ease
d in
co
ncen
tratio
n sh
ould
be
grad
ually
incr
ease
d in
1%
incr
emen
ts (a
t 41%
incr
emen
ts (a
t 4-- 6
L/m
in fl
ow ra
te) e
very
few
bre
aths
unt
il 6
L/m
in fl
ow ra
te) e
very
few
bre
aths
unt
il de
sire
d an
esth
etic
dep
th is
reac
hed
desi
red
anes
thet
ic d
epth
is re
ache
d
••Fr
esh
gas
flow
rate
s m
ay b
e re
duce
d to
1Fr
esh
gas
flow
rate
s m
ay b
e re
duce
d to
1-- 3
L/m
in o
nce
adeq
uate
3
L/m
in o
nce
adeq
uate
an
esth
etic
dep
th is
atta
ined
bec
ause
of t
he ra
pid
appr
oach
of
anes
thet
ic d
epth
is a
ttain
ed b
ecau
se o
f the
rapi
d ap
proa
ch o
f al
veol
ar to
insp
ired
conc
entra
tions
with
alve
olar
to in
spire
d co
ncen
tratio
ns w
ithde
sflu
rane
desf
lura
ne
••D
esflu
rane
Des
flura
neco
ncen
tratio
ns o
f les
s th
an 6
% ra
rely
pro
duce
clin
ical
co
ncen
tratio
ns o
f les
s th
an 6
% ra
rely
pro
duce
clin
ical
m
anife
stat
ions
of a
irway
irrit
atio
n or
sym
path
etic
stim
ulat
ion
man
ifest
atio
ns o
f airw
ay ir
ritat
ion
or s
ympa
thet
ic s
timul
atio
n
••S
uch
effe
cts
may
be
min
imiz
ed b
y ad
min
iste
ring
anes
thet
icS
uch
effe
cts
may
be
min
imiz
ed b
y ad
min
iste
ring
anes
thet
icad
juva
nts
adju
vant
s(( e
geg, N, N
22O,
O, o
pioi
dsop
ioid
s , o
r a s
hort
, or a
sho
rt-- a
ctin
g be
ta b
lock
er)
actin
g be
ta b
lock
er)
Sup
rane
Sup
rane
®®(d
esflu
rane
) pre
scrib
ing
info
rmat
ion.
(des
flura
ne) p
resc
ribin
g in
form
atio
n.
Des
flur
ane
Mai
nten
ance
:T
itra
ting
Ane
sthe
tic
Dep
th
•Whe
n al
teri
ng a
nest
heti
c de
pth,
incr
ease
or
decr
ease
de
sflu
rane
conc
entr
atio
n in
in
crem
ents
of
1% a
nd in
crea
se
the
fres
h ga
s fl
ow r
ate
to 4
-6
L/m
in u
ntil
the
desi
red
anes
thet
ic d
epth
is r
each
ed
Ane
sthe
tic
titr
atio
n
•A
nest
heti
c de
pth
can
be m
ore
rapi
dly
titr
ated
wit
h de
sflu
rane
than
wit
h is
oflu
rane
. Thi
s al
low
s m
ore
rapi
d co
ntro
l of
elev
ated
bl
ood
pres
sure
res
ulti
ng f
rom
su
rgic
al s
tim
ulus
Avr
amov
MN
et
al. A
nest
hA
nalg
.199
8;87
:666
-670
.
Des
flur
ane
Mai
nten
ance
:E
mer
genc
e an
d th
e P
osto
pera
tive
P
erio
d
Em
erge
nce
Rec
omm
enda
tion
s•
Per
form
all
airw
ay m
anip
ulat
ion
and
suct
ioni
ng w
hile
pat
ient
is a
dequ
atel
y an
esth
etiz
ed•
If p
atie
nt is
intu
bate
d, c
onsi
der
extu
bati
on w
hile
pat
ient
is a
dequ
atel
y an
esth
etiz
ed•
Avo
id s
tim
ulat
ion
duri
ng s
tage
II
anes
thes
ia•
To
min
imiz
e or
att
enua
te c
ough
dur
ing
emer
genc
e, a
dmin
iste
r a
smal
l dos
e of
op
ioid
, pro
pofo
l, or
lido
cain
e
Em
erge
nce
Sig
nifi
canc
e of
Rap
id A
wak
enin
g S
een
Wit
h D
esfl
uran
e•
Ear
lier
asse
ssm
ent
of c
ogni
tive
fu
ncti
on is
pos
sibl
e•
Ear
lier
reve
rsal
of
mus
cle
rela
xant
s sh
ould
be
cons
ider
ed•
Ear
lier
asse
ssm
ent
of a
nalg
esic
ne
eds
may
be
nece
ssar
y
Att
enua
ting
Sym
path
etic
S
tim
ulat
ion
Wit
h Fe
ntan
yl, E
smol
ol,
or C
loni
dine 02040608010
0
% o
f Con
trol a
t Pe
ak C
V Re
spon
se
Hear
t Rat
eM
AP
Fent
anyl
1.5
mcg
/kg
Fent
anyl
4.5
mcg
/kg
Esm
olol
0.7
5 m
g/kg
Clon
idin
e 4.
3 m
cg/k
g
**
*
*
**
*
* P
<.05
vs.
con
trol (
no d
rug)
* P
<.05
vs.
con
trol (
no d
rug)
Wei
skop
f et a
l. A
nest
hesi
olog
y. 1
994;
81:1
350.
Car
diov
ascu
lar
Eff
ects
of
Des
flur
ane
in A
dult
s: S
umm
ary
•D
esfl
uran
e de
crea
ses
arte
rial
pre
ssur
e,
syst
emic
vas
cula
r re
sist
ance
, and
m
yoca
rdia
l con
trac
tilit
y, a
nd in
crea
ses
hear
t ra
te; t
hese
eff
ects
are
sim
ilar
to
thos
e se
en w
ith
isof
lura
ne
•D
esfl
uran
e an
d is
oflu
rane
pro
duce
sim
ilar
hem
odyn
amic
eff
ects
dur
ing
CA
BG
sur
gery
(s
imila
r in
cide
nce
of is
chem
ic e
vent
s an
d ad
vers
e ca
rdia
c ou
tcom
es)
Car
diov
ascu
lar
effe
cts
sum
mar
y•
Des
flur
ane
may
tra
nsie
ntly
incr
ease
blo
od
pres
sure
and
hea
rt r
ate
whe
n co
ncen
trat
ions
are
rap
idly
incr
ease
d ab
ove
1 M
AC
; opi
oid
prem
edic
atio
n ca
n m
inim
ize
thes
e ef
fect
s
•D
esfl
uran
e m
ay b
e ra
pidl
y ti
trat
ed,
prov
idin
g fa
ster
con
trol
of
the
hem
odyn
amic
sta
te c
ompa
red
to is
oflu
rane
Com
pone
nts
of
Ane
sthe
sia
Cos
t•D
rugs
•Equ
ipm
ent
•Med
ical
per
sonn
el•O
R, P
AC
U, a
nd r
ecov
ery
tim
e•
1998
OR
Cos
t at
Sta
nfor
d U
nive
rsit
y:-O
R: a
ppro
x. $
14/m
in*
-PA
CU
: app
rox.
$3/
min
*•
Tod
ay•
OR
: app
rox.
$40
/min
•P
AC
U a
ppro
x. $
20/m
in
*Cos
t rou
nded
*Cos
t rou
nded
-- off
to th
e ne
ares
t dol
lar
off t
o th
e ne
ares
t dol
lar
Cos
t of
Inh
aled
Age
nts
Res
ults
Fro
m a
n In
terp
lay
of F
acto
rs•
Cos
t pe
r m
illili
ter
of li
quid
age
nt
•V
olum
e of
vap
or f
rom
eac
h m
illili
ter
of li
quid
•E
ffec
tive
pot
ency
of
agen
t (c
once
ntra
tion
tha
t m
ust
be
deliv
ered
fro
m v
apor
izer
to
prov
ide
appr
opri
ate
leve
l of
anes
thes
ia)
•B
ackg
roun
d fl
ow o
f ga
ses
Cos
t D
urin
g M
aint
enan
ce P
hase
of
Inh
aled
Age
nts
at 1
L/m
in
FGF
Age
nt1
MA
C*
mL
vapo
r/
mL
liqui
d/
Cos
t/m
LC
ost/
h m
inm
inIs
ofor
ane
0.42
%4.
220.
022
$0.2
1$0
.27
Sev
oflu
rane
0.62
%6.
240.
084
$0.7
6$3
.80
2L/m
in F
GF
Des
flur
ane
2.17
%22
.18
0.10
5$0
.37
$2.3
3
* W
ith
67%
N2O
.
Cro
ssov
er t
echn
ique
051015202530
Com
man
dO
rient
atio
n
Des
flura
neC
ross
over
Isof
lura
ne
Switc
hing
Fro
mS
witc
hing
Fro
mIs
oflu
rane
Isof
lura
netoto
Des
flura
neD
esflu
rane
Min
utes
M
inut
es
From
End
of
From
End
of
Ane
sthe
sia
Ane
sthe
sia
to R
espo
nse
to R
espo
nse
* P<.
01 v
s cr
osso
ver
* P<.
01 v
s cr
osso
ver
and
isof
lura
nean
d is
oflu
rane
Neu
man
n et
al.
Ane
sthe
siol
ogy.
199
8;88
:914
.N
eum
ann
et a
l. A
nest
hesi
olog
y. 1
998;
88:9
14.
**
So
wha
t is
the
idea
l rec
ipe
for
deliv
ery
of a
n in
hale
d an
esth
etic
?•
Rap
id a
nd s
moo
th in
duct
ion
•U
se a
pot
ent
inha
led
anes
thet
ic
wit
h lo
w s
olub
ility
tha
t pr
ovid
es
amne
sia
•U
se lo
w in
flow
rat
es•
Eco
nom
ical
•M
aint
ains
nor
mot
herm
ia
Rec
ipe
cont
’d
•D
esfl
uran
e vs
. Sev
oflu
rane
vs.
Is
oflu
rane
•S
evof
lura
ne m
ay b
e le
ss e
cono
mic
al in
lo
nger
cas
es b
ecau
se s
houl
d no
t us
e lo
w in
flow
rat
es (
<1 L
/min
) fo
r m
ore
than
2
hour
s•
Neu
rom
uscu
lar
bloc
kade
•R
apid
aw
aken
ing
•Lo
wer
sol
ubili
ty
fast
er w
akeu
p•
Inci
denc
e of
PO
NV
/PD
NV
Rec
ipe
cont
’d
•P
osto
pera
tive
pai
n•
Less
rap
idly
elim
inat
ed in
hale
d an
esth
etic
s m
ay a
ctua
lly c
ause
hy
pera
lges
ia a
t ~
0.1
MA
C a
nd
incr
ease
the
per
cept
ion
of
post
oper
ativ
e pa
in
Tha
nks
and
have
a g
reat
su
mm
er!
